There are two angles of attack to cutting catheter-associated urinary tract infection (CAUTI) rates by 25%, and the harder approach involves changing provider behavior.
"One of the things we find in the literature is that changing the mindset of people really takes time," says Linda Greene, RN, MPS, CIC, one of the six representatives of the Association for Professionals in Infection Control and Epidemiology (APIC) on the national faculty of the On the CUSP: Stop CAUTI initiative.
"Ideally, we want to set aggressive goals," Greene says. "You want a stretch goal, and it is very aggressive."
A preliminary report released last fall showed a 16% decrease in CAUTI. These results were mostly achieved through technical changes, following the evidence, Greene notes.
Changing practices involving technique is the low-hanging fruit. Staff can learn to insert properly, use antiseptic technique, and make sure the bag is secured and below the bladder, she says.
Many hospitals have made these evidence-based practice changes already, and that’s why initial results look good. Bridging the gap between 16% and 25% will be more challenging. The next step is to tackle socio-adaptive, behavioral changes.
"How do we get evidence to the bedside, and how do we make sure doctors and nurses are very engaged, making urinary tract infection prevention a priority?" Greene asks. "Not every patient needs a urinary catheter, so how do we find ways to initiate physician reminders or protocols that instruct the nurse to pull the catheter when it’s not needed?"
To illustrate the challenges of changing culture and behavior, Greene offers an example of ICU practice.
"In the CDC guidelines one of the indications for urinary catheter is output monitoring of a critically ill patient," she explains.
"For years, people thought if you were in the ICU you needed a catheter to see how much [urine] you’re putting out," she adds. "But now we know that many ICU patients don’t need to be monitored that closely, or they can be monitored by other means."
For CUSP to work, it needs to blend the evidence-based changes with socio-adaptive changes, making both a part of the hospital’s value system, she says.
Greene understands from personal experience why the socio-adaptive changes are so difficult.
"I’ve been a nurse since I was 19, working in emergency rooms, ICUs, and the mantra was you put in an IV and catheter," Greene says. "We thought we were doing the right things for patients, but now we know that some of these things are not necessary to use for as long as we once thought."
When Greene worked at a busy hospital years ago she resisted the hospital’s attempts to focus more on UTIs.
"I said, Quite frankly, I have bigger fish to fry.’ If they think a patient has a UTI, then we’ll give a drug and the patient will be fine," she recalls.
What she’s learned since is that giving out antibiotics has consequences, and urinary catheters can harm patients in a number of ways, including leading to bedsores.
"It’s a change of thinking, and that change of thinking can get us to that next level," Greene says.
APIC will assist hospitals with making these cultural and behavioral changes through an army of CUSP leaders, including 35-40 fellows, most of whom are infection preventionists. Launched in May, the fellow program has each IP doing a project on CAUTI, submitting a performance improvement project and going through intense training, and work with mentors like Greene and the other CAUTI faculty.
The fellows return to their organizations to interview staff and executives. They explain what the Stop CAUTI initiative is about and help their hospitals establish initiatives to work collaboratively to reduce CAUTI.
Another strategy is to showcase hospitals that have achieved zero CAUTI rates.
"I was on a call last week with a Florida hospital that had gone two years without a CAUTI, and she was sharing her strategies," Greene says. "There is no better way to help people get to where they need to be than through story-telling by the people who have been able to achieve the results they need."
Success stories resonate with everyone, she notes.
"One of the big mistakes we make in health care is to try to go in and educate people before we really engage them," Greene says. "It’s better to get people engaged and help them understand why it’s important before you educate them and share strategies."
Hospitals can accelerate CAUTI reduction rates by implementing strategies that make use of electronic health records. They can make stop orders or protocols regarding catheter use.
"We are seeing a number of hospitals where the catheter that is inserted for surgery is removed in the post-anesthesia care unit," Greene notes.
"The other thing that is beginning to catch on, and it’s been a little slower, is appropriately collecting urine cultures," she says.
The idea is that urine cultures often are ordered inappropriately, resulting in unnecessary antibiotic use, she adds.
"If a patient is not symptomatic — even if there are organisms in the culture — then do not treat asymptomatic bacteremia," Greene says.
As hospitals and providers adopt Stop CAUTI changes there also are opportunities to improve results further through patient and family education.
"Let’s say I’m going for surgery and they’re going to put a catheter in me," Greene says. "Instead of saying, You’ll have this catheter and it might be uncomfortable, but we’ll take it out when you no longer need it,’ you can say, We’ll put this in and take it out the next day because we don’t want you to get an infection.’"
The idea is to set expectations for patients and their families that the catheter is temporary.
"This sets up a patient and family to ask a question about the catheter if it’s been forgotten," Greene adds.